A - Page 2

ANESTHESIA | January 1, 2026

ADMINISTRATION OF MODERATE SEDATION – INTRAVENOUS – FIRST 15 MINUTE INCREMENT, OR ANY PORTION THEREOF

Supporting Structures | January 1, 2026

PLACEMENT OF INTERIM IMPLANT ABUTMENT

PERIODONTICS | SURGICAL SERVICES (INCLUDING USUAL POSTOPERATIVE CARE) | January 1, 2026

BONE REPLACEMENT GRAFT – RETAINED NATURAL TOOTH- FIRST SITE IN QUADRANT

PERIODONTICS | SURGICAL SERVICES (INCLUDING USUAL POSTOPERATIVE CARE) | January 1, 2026

BONE REPLACEMENT GRAFT- RETAINED NATURAL TOOTH- EACH ADDITIONAL SITE IN QUADRANT

OTHER RESTORATIVE SERVICES | January 1, 2026

PLACEMENT OF INTERIM DIRECT RESTORATION